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COMM E N TAR Y Open Access
The changing trends in tobacco smoking for
young Arab women; narghile, an old habit with a
liberal attitude
Najla S Dar-Odeh
1*
and Osama A Abu-Hammad
2
Abstract
Narghile smoking by young females is becoming more acceptable than cigarettes in the conservative societies of
Arab countries. Lack of social constraints on narghile smoking has resulted in an increased prevalence of narghile
smoking among young Arab females and an earlier age of onset of this habit when compared to cigarette
smoking.
Documented health hazards of narghile smoking including pulmonary, cardiovascular and neoplastic ailments are
consequently expected to affect this vulnerable sector of the population together with their offspring. In this
commentary, we shed some light on the changing tren d of tobacco use among young Arabic women as shown
by an increasing number of studies investigating habits of tobacco use in young people.
Keywords: narghile, young Arab females, tobacco
Prevalence of narghile smoking among young
Arab females
Although cigarette smoking is the most common type of
tobacco use worldwide, narghile smoking (NS) is spread-
ing globally to affect Arabic and western societies.
Recent studies have demonstrated a high prevalence of
NS among females in many Arabic countries [1-5]. NS
is one of the social habits that shape the general forms
of A rabic folklore. It is considered socially acceptable by
a substantial proportion of the society including young
females. This lenient role of the society in accommodat-
ing or even encouraging females to smoke narghile,
seems to override the efficient role of religion. Islam is

the religion of most Arabs and it essentially demands
paying attention to own health as well as public health
[6]. Religious authorities and clerics emphasize this atti-
tude towards NS to the public over the media and dur-
ing Friday prayers. Among Muslim populations,
smoking is conside red inappropriate for girls, is unlady-
like, and may ruin a girl’s reputation and prospects for
marriage [7]. Hence, cigarette smoking has always been
a limited or a concealed habit within the Arabic female
population particularly unmarried ones. However, the
trend of NS has changed the picture and Arabic females
-whether married or not- can now smoke narghile in
the open without feeling embarrassed or ashamed about
it. This permissive role of the society also delivers a
wrong message about narghile safety to the public.
Many health professionals perceive smoking narghiles as
being less harmful than cigarette smoking or even not
harmful based on the presumption that the inhaled
smoke is filtered through water [8].
Several studies conducted in most Arabic countries
showed that NS is growing in popularity among young
fem ales , and trends have shifted between tobacco types,
with NS becoming the preferred form of tobacco use for
women [9].
Statistics for the prevalence of NS among young Arab
fem ales are disturbing (table-1) particularly in countries
like Egypt [5], Lebanon [10,11], Jordan [2,3] and Syria
[1]. Prevalence was also relatively high among Palesti-
nian girls [4] and those in the gulf region [12]. Data
from more conservative societies like t hose of Saudi

Arabia were scarce as the studies conducted there inves-
tigated only males [12,13]. A recently published study,
* Correspondence:
1
Department of Oral and Maxillofacial Surgery, Oral Medicine and
Periodontics, Faculty of Dentistry, University of Jordan, Queen Rania Street,
Amman, 11942, Jordan
Full list of author information is available at the end of the article
Dar-Odeh and Abu-Hammad Harm Reduction Journal 2011, 8:24
/>© 2011 Dar-Odeh and Abu-Hammad; licensee BioMed Central Ltd. Thi s is an Open Access article d ist ributed under the terms of the
Creative Commons Attribution License (http://creativecommons .org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
however, showed that about half of the smoker female
students in a Saudi university smoke narghile, while the
other half smoke cigarettes [14].
With the exception of Tunisia [15] in which more
girls in the age group of 13-17 years favor cigarettes
(1.1%) over narghile (0. 2%), the female preference for
narghile is obvious, confirming the influential role
society plays in shaping smoking behavior of young
females.
Risks of NS by young females
Studies investigating the effects of NS on health are
increasingly reporting its adverse effects. The habit is
associated with increased risk of chronic obstructive air-
way disease as well as adverse cardio vascular effects like
increased blood pressure [16-19] There have also been
reports of its association with some types of cancer such
as bronchogenic carcinoma, oesophageal carc inoma,
bladder cancer and pancreatic cancer [20-23] The reader

can refer to a number of reviews writte n in this regards
[24-27].
Moreover, one can not consider NS as a “safer” alter-
native to cigarettes when discussing the important issues
of young age and female gender.
It is o bvious from the studies investigati ng prevalence
of NS in the Arabic countries that females opt for the
narghile and they do so unacceptably at the young age
of early adolescence. Exposure to any form of tobacco at
young age is expected to increase the risk of tobacco-
associated disease. A strong correlation seems to exist
between incidence of oral cancer and the age of onset of
tobacco use [28]. Consequently, a higher incidence of
oral cancer in men and women of younger age group is
seen in developing countries than in the United States
for example [28].
Another important aspect pertaining to the young age
of female narghile smokers is pregnancy. It was shown
that smoking one or more narghiles a day during preg-
nancy is associated with at least a 100 g reduction in
the adjusted m ean birth weight of babies [8]. In addi-
tion, babies born to women smoking narghile during
pregnancy have a higher proportion of other problems,
such as pulmonary diseases [8]. Even for women who
are ready to give up smoking when pregnant, some may
not be aware of their pregn ancy, and hence they co n-
tinue smoking. Unfortunately, the risk of having babies
of low birth weight almost triples among those who
smoke narghiles in the first trimester [8].
Café narghile smoking

Young narghile smokers prefer usually to socialize with
their friends in cafés during narghile smoking [3,5]. Dur-
ing these social gatherings many of them share one nar-
ghile set through using its hose tip, so that the narghile
hoseistransferredfromhandtohandandfrommouth
to mouth. This process can be a substantial source of
cross infection [3]. Although some cafés offer disposable
hose tips or a disposable hose (ironically called “ the
hygienic hose” ), most narghile smokers use the regular
hose but not the hygienic hose (Figure-1). This could be
due to the extra cost of the hygienic hose, consequ ently
it is only offered by the elite cafés. In addition, many
people are n ot aware of its availability, or simply they
dislike it because it does not provide a smooth smoking
technique in contrast to the conve ntional hose, whic h
has a relatively large diameter that demands a less suc-
tion power (Figure-1). Another disposable part that is
more popular t han the hygienic hose is the disposable
plastic tip which is inserted in the mouth. This part
called the “Mabsam” (mouth in Arabic) is usually made
of plastic (Figure-1). The potential health hazards of the
prolonged use of plastic “Mab sams” has not been inves-
tigated yet, and should not be overlooked, particularly
that it may become heated during the s moking proce-
dure, if the liquid in the water tanks does not adequately
cool the smoke. The water chamber in narghile is cap-
able of absorbing part of the toxic chemicals associated
with tobacco burning, ho wever, there is no guarantee
that this water i s frequently changed by the café staff or
that the chamber is regularly cleaned. T his puts i n

Table 1 Prevalence of narghile smoking among young
females of the Arabic states
Researchers Country Age Category Prevalence
Labib et al (2007)[5] Egypt University students 37.8%
Maziak et al (2004)[1] Syria University students 4.9%
Azab et al (2010)[2] Jordan University students 19%
Al-Mulla et al (2008)[12] Gulf states 13-15 years 6.4%-12%
Mandil et al (2010)[14] Saudi Arabia University students 2%
Tamim et al (2003)[10] Lebanon University students 23.4%
Harrabi et al (2010)[15] Tunisia 13-17 years 0.2%
Figure 1 Disposable parts of the narghile used in cafes: A,
regular hose is understandably associated with cross infection.
B, disposable (hygienic) hose have less diameter making smoking
less preferable. C, disposable tips (mabsams) made of plastic posing
health hazards.
Dar-Odeh and Abu-Hammad Harm Reduction Journal 2011, 8:24
/>Page 2 of 4
doubt the ability of this water chamber to remove away
toxic materials from the smoke.
Another debatable issue of NS is the head of the nar-
ghile which is usually made of ceramic. At cafés some
ladies request that the head of the narghile to be pre-
pared of fruits like apple for example (Figure-2, a). The
head is made of ha lf an apple by m aking it hollow in
the middle with a hole prepared at the base t o allow for
smoke passage down to the water tank. Byproducts of
tobacco burning into an apple with an ignited and burn-
ing charcoal at the top have not been examined yet nor
have their adverse health effects been investigated.
In some of the Middle Eastern countries, the water

tank is replaced with a watermelon, a melon, or even a
coconut t hat is made hollow from the inside to accom-
modate the water (Figure-2, b). The effect of passing
tobacco smoke onto the insides of these fruits is yet to
be explored.
Discussion
Empowerment of women is an important trend affecting
most Arabic countries. Consequently, Arabic women
can now enjoy a number of privileges like higher educa-
tion, better career opportunities and as a result an
increased spending power. Numbers o f women judges,
ministers, members of parliament etc. are on the rise.
Unfortu nately, many customers of the elite cafés serving
narghile in many Arabic cities are actually highly edu-
cated, successful women from better-off families. This
image contributes to encouraging NS among younger
generations particularly female adolescents.
Social pressure and antismoking campaigns are being
directed against cigarette smoking and have been rela-
tively successful in limiting cigarette smoking by females
in Arabic countries. Furthermore, laws banning smoking
in public premises have contributed to the reduced
numbers of cigarette smokers. On the other hand, there
are no laws forcing narghile café owners to check the
age of their customers or to monitor the “hygiene” of
their narghiles.
Family role in combating the habit of NS seems to be
lacking. On the contrary, a family member like a father, a
sister, a brother, or a mother could be the one introdu-
cing NS to the young adolescent female relative. The lack

of awareness on narghile hazards added to the absent
role model of mothers smoki ng narghile cont ributes lar-
gely to encouraging narghile use among young females.
Globalization in the era of social networking and
information technology has minimized the role of the
family and transformed it into a rather permissive and
more lenient attitude. Young people in the Arab world
are no longer compliant as they used to be, and they
would like to argue on many issues including social
habits like the narghile.
The World Health Organization in collaboration with
the ministries of health pl ay a major role in delivering
educational programs not only to the school students
but also to the parents who should play a more active
role in understanding and communicating with their
children.
Since peer pressure is a well-recognized aspect as far
as narghile smoking is concerned, it is important to
involve young generation in the fighting of the narghile
epidemic.
On the other hand, governments can, and should, play
an active role in regulating the work of cafés serving
narghile, whereby regular periodic checks are performed
on the café facilities, and whe n necessary, the confisca-
tion of instruments that do not comply with medical
and hygienic standards. Furthermore, public should be
made aware of the availability of disposable part s of the
narghile like hoses and tips to reduce the communicable
diseases.
To that end, it is of prime importance that research is

established to investigate whether the “hy gienic hoses”
and the disposable “ mabsams” are as hygienic as they
are thought to be
Conclusion
In conclusion, data pertaining to the health hazards of
narghile has to be distributed outside scientific journals;
it is the right of the public to be aware of the ri sk of
NS. Ministries of health in Arabic countries should play
a more active role in licensing, and monitoring narghile
cafés.
Acknowledgements
The authors would like to thank Professor Farouk Shakhatreh from University
of Jordan for his valuable remarks. They also appreciate the help of Mr.
Ahmad Jaber- a dental student at the University of Jordan- for preparing the
pictures.
Author details
1
Department of Oral and Maxillofacial Surgery, Oral Medicine and
Periodontics, Faculty of Dentistry, University of Jordan, Queen Rania Street,
Figure 2 The use of some fruits in replacement of narghile
parts is preferred by many female café customers. A: Ceramic
narghile head is replaced with an apple. B: A watermelon is used to
replace the water tank of the narghile.
Dar-Odeh and Abu-Hammad Harm Reduction Journal 2011, 8:24
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Amman, 11942, Jordan.
2
Department of Prosthodontics, Faculty of Dentistry,
University of Jordan, Queen Rania Street, Amman, 11942, Jordan.
Authors’ contributions

ND and OA have contributed equally to writing this commentary. Both of
them have read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 8 January 2011 Accepted: 30 August 2011
Published: 30 August 2011
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doi:10.1186/1477-7517-8-24
Cite this article as: Dar-Odeh and Abu-Hammad: The changing trends in
tobacco smoking for young Arab women; narghile, an old habit with a
liberal attitude. Harm Reduction Journal 2011 8:24.
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